When you enroll in DeltaCare USA, you select a PMI network dentist to provide your dental care. With DeltaCare USA, you must visit your selected primary care dentist in order to receive benefits. When you need specialty care, your primary care dentist can obtain a referral. Advantages of the DeltaCare USA plan include low or no copayments for services, no deductibles and no maximums on services provided by primary care dentists. Dues are easy to afford: Only $135 per year for a single membership PLUS a one-time $15 administration fee
Dues are easy to afford:
Only $135 per year for a single membership PLUS a one-time $15 administration fee
Diagnostic Services No Cost - $ 5 Preventive Services No Cost - $150 Restorative Services No Cost - $425 Endodontic Services $ 25 - $725 Periodontic Services $ 50 - $650 Prosthodontic Services, Removable $ 20 - $600 Prosthodontic Services, Fixed $ 25 - $425 Oral and Maxillofacial Surgery $ 35 - $230 Orthodontic Services No Cost - $2,700 Adjunctive General Services No Cost - $70 NOTE: Some services may not be covered. Certain services may be covered only if provided by specified providers, or may be subject to an additional charge. Limitations apply to the frequency with which some services may be obtained. For example: cleanings are limited to once in each 6-month period; replacment of removable and fixed dentures and crowns is limited to once in any 5-year period. (D) Outpatient Services Not Covered (E) Hospitalization Services Not Covered (F) Emergency Health Coverage The Enrollee may receive a maximum Benefit up to $100 per emergency, per Enrollee. (G) Ambulance Services Not Covered (H) Prescription Drug Services Not Covered (I) Durable Medical Equipment Not Covered (J) Mental Health Services Not Covered (K) Chemical Dependency Services Not Covered (L) Home Health Services Not Covered (M) Other Not Covered Each individual procedure within each category listed above, and which is covered under the Program has a specific Copayment, which is shown in the Schedule of Benefits and Copayments in this Disclosure Form/Contract.
NOTE: Some services may not be covered. Certain services may be covered only if provided by specified providers, or may be subject to an additional charge.
Limitations apply to the frequency with which some services may be obtained. For example: cleanings are limited to once in each 6-month period; replacment of removable and fixed dentures and crowns is limited to once in any 5-year period.
Each individual procedure within each category listed above, and which is covered under the Program has a specific Copayment, which is shown in the Schedule of Benefits and Copayments in this Disclosure Form/Contract.
You will need Adobe® Reader to view PDF documents. Download a copy of Adobe Reader from the Adobe website if needed. Download DeltaCare USA Senior DHMO .pdf Application DeltaCare USA DHMO Dentist Network Database YOU MUST CHOOSE A PRIMARY DENTIST TO PUT ON OUR APPLICATION.
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